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Clinical Skills > Medical History > Flashcards

Medical History Flashcards

1
Q

Clinical Skills

What percent of the time does an exceptional history-taking indicate the correct diagnosis?

A

75%

(the review of systems is then confirmatory)

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2
Q

Clinical Skills

What are the initial steps in establishing a rapport with a patient before beginning to take their history?

A

Introduce yourself (your role and purpose in talking to them) and acknowledge their fear and/or pain;

make sure the surrounding area is private and quiet; sit down at eye level;

ask family members to step out if necessary;

do NOT interrupt for at least 30 seconds;

be conscious of their comfort level and ability to express their needs (consider any necessary language and cultural adaptations)

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3
Q

Clinical Skills

What is the first part of a successful history? (1/5 and 2/5)

A
  1. Chief complaint
  2. History of present illness
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4
Q

Clinical Skills

Which mnemonic is useful in taking a history of present illness?

A

FAR COLDER

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5
Q

Clinical Skills

What is the second part of a successful history? (3/5)

(after chief complaint and HPI)

A
  1. Medical history

(including medications (doses and indications) and allergies)

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6
Q

Clinical Skills

Which mnemonic is useful in taking a past medical history?

A

I3 SAM

Illnesses, Injuries, Immunizations Screening, Allergies, Medications

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7
Q

Clinical Skills

What is the final part of the history taking process before beginning the review of systems? (4/5 and 5/5)

(after CC, HPI, and medical history)

A
  1. Family history
  2. Social history
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8
Q

Clinical Skills

Which mnemonic is useful in taking a social history?

A

LEO-DSST

Living situation, Education, Occupation, Diet/exercise, Substance use, Sexual history, Travel

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9
Q

Clinical Skills

What are the main two parts of a chief complaint?

A

Symptom(s) + duration

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10
Q

Clinical Skills

What mnemonic is useful in establishing a complete history of the present illness? For what does it stand?

A

FAR COLDER

Frequency

Associated symptoms

Radiation

Character

Onset

Location

Duration

Exacerbating factors

Relieving Factors

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11
Q

Clinical Skills

Outline the ‘FAR’ in the FAR COLDER mnemonic regarding HPIs.

A

Frequency

Associated symptoms

Radiation

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12
Q

Clinical Skills

Outline the ‘COLDER’ in the FAR COLDER mnemonic regarding HPIs.

A

Character

Onset

Location

Duration

Exacerbating factors

Relieving Factors

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13
Q

Clinical Skills

What is the mnemonic FAR COLDER?

A

A S/Sy outline for the history of present illness

(Frequency, associated symptoms, radiation, character, onset, location, duration, exacerbating factors, relieving factors)

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14
Q

Clinical Skills

What type of questions are most useful in gaining a patient’s side of the story and making them feel validated?

A

Open-ended questions

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15
Q

Clinical Skills

What is the F in the FAR COLDER mnemonic for HPIs?

A

Frequency

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16
Q

Clinical Skills

What is the A in the FAR COLDER mnemonic for HPIs?

A

Associated symptoms

17
Q

Clinical Skills

What is the R in the FAR COLDER mnemonic for HPIs?

18
Q

Clinical Skills

What is the C in the FAR COLDER mnemonic for HPIs?

19
Q

Clinical Skills

What is the O in the FAR COLDER mnemonic for HPIs?

20
Q

Clinical Skills

What is the L in the FAR COLDER mnemonic for HPIs?

21
Q

Clinical Skills

What is the D in the FAR COLDER mnemonic for HPIs?

22
Q

Clinical Skills

What is the E in the FAR COLDER mnemonic for HPIs?

A

Exacerbating factors

23
Q

Clinical Skills

What is the second R in the FAR COLDER mnemonic for HPIs?

A

Relieving factors

24
Q

Clinical Skills

How should the chief complaint be recorded?

A

In the patient’s own words

25
Q

​Clinical Skills

What 4 factors make up the main family history?

A

1. Mother

2. Father

3. Siblings

4. Genetic pedigrees (if warranted)

26
Q

​Clinical Skills

What is the general order of the medical interview?

A

Chief Complaint >

History of Present Illness >

Medical history >

Social history >

Family history >

Review of systems

27
Q

​Clinical Skills

Identify what percentage of the time is the diagnosis made by each of the following steps in the patient experience:

The medical interview

Review of systems

Lab results

A

The medical interview - 75-80%

Review of systems - 10-15%

Lab results - 5-10% (I.e., the review of systems and lab results are generally confirmatory in nature as to any particular diagnosis)

28
Q

​Clinical Skills

How should you wrap up a medical interview with a patient?

A

Recap everything that was discussed to make sure you’re not missing anything

29
Q

​Clinical Skills

How can you make the illicit substances and sexual history portions of the medical interview easier for the patient?

A

Before beginning these portions, remind them of the confidentiality they have with you and the attending AND remind them they don’t have to answer any questions, but it is in their best interest to give you a clear understanding of who they are

30
Q

​Clinical Skills

What is a simple way to help patients feel that their opinion is valued during the medical interview?

A

Ask them what they think the cause of their chief complaint is / get their input –> this also helps us see their perspective on the issue

31
Q

​Clinical Skills

What are the main topics to be covered in ascertaining the patient’s medical history?

PAMSAS

A

Past diagnoses

Accidents / injuries

Medications

Surgical Hx

Allergies (to medications and not)

Screenings / Immunizations

(also, travel, hx of transfusion, etc.)

32
Q

​Clinical Skills

What 5 factors make up the main social history?

1. _______________

2. _______________

3. Education / occupation

4. Diet / exercise

5. Sexual History

A

1. Family / living environment

2. Alcohol / Tobacco / Drugs

3. Education / occupation

4. Diet / exercise

5. Sexual History

33
Q

​Clinical Skills

What 5 factors make up the main social history?

1. Family / living environment

2. Alcohol / Tobacco / Drugs

3. _____________

4. _____________

5. Sexual History

A

1. Family / living environment

2. Alcohol / Tobacco / Drugs

3. Education / occupation

4. Diet / exercise

5. Sexual History

34
Q

​Clinical Skills

What 5 factors make up the main social history?

1. _____________

2. Alcohol / Tobacco / Drugs

3. Education / occupation

4. Diet / exercise

5. _____________

A

1. Family / living environment

2. Alcohol / Tobacco / Drugs

3. Education / occupation

4. Diet / exercise

5. Sexual History

35
Q

​Clinical Skills

In taking a patient history, what questions should be asked about medications?

A
  • Over-the-counter Rx
  • Prescription Rx
  • Allergies
36
Q

​Clinical Skills

What is an appropriate way to ask a patient’s sexual orientation in clear, easily understood terms?

A

Are you sexually active with men, women, or both?

Clinical Skills (14 decks)

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